SURGICAL SAFETY CHECKLISTS Power Play: Managing the Forces that - - PowerPoint PPT Presentation

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SURGICAL SAFETY CHECKLISTS

Power Play: Managing the Forces that Impact Implementation

The Experience of a small isolated community hospital

Presentation by: Mark Balcaen. March 8 -9 , 2010

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Background

• Kenora (230 km from Winnipeg)
• 84 beds (Med/Surg/Mat/Peds/Psych/Chr)
• 2 General Surgeons
• 3 Visiting Specialist Surgeons
• 8 Dentists and 3 GP’s Doing Minor Surgery
• 5 GP Anesthetists
• 8 Surgical Services Nursing Staff (3 OR’s)
• 2400 Surgeries / Procedures per Year (80%+ NFA)
• Ontario Wait Times Strategy Site

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Previous Practice

• Nursing OR Checklists.
• Surgeons Preference Cards.
• Procedure Consent Form.
• Patient May Have Been Anesthetized Prior to Entire

Surgical Team in the OR.

• Communication problems between ST members.

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Impetus to Adopt

• Lack of Mind-Reading OR Nursing Staff
• Incident Reports related to Intraoperative Issues

 OR Lab Specimen Errors  OR Equipment and Supplies Issues  Anesthesia Related Incidents

• Possible Means to Address Long-Standing OR

Communication Issues

• Desire to be “ahead” rather than to “Catch-up”
• No Significant Additional Resources Needed

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Roll Out Approach

• Slowly
• Gain Support as You Go
• Identify Key Champions
• Excellent CPSI Tool Kit
• Persistence

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Implementation

• Feb 19/09

SSL Presentation to Hospital SSC and Senior Management Apr 10/09 Trial Checklist in OR Evaluate Checklist Trial Revise Checklist as Necessary Retest Checklist Start Monitoring and Recording Results

• Apr 23/09

Report Successes, Good Catches, Near Misses. Make Checklist Modifications Continue Monitoring Results

• Apr 30 / 09 Brief SS Group on Findings

Celebrate Successes

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General Surgery

SURGICAL SAFETY

CHECKLIST

www.safesurgerysaveslives.ca

Your Organizational Logo Your Organizational Logo Your Organizational Logo Your Organizational Logo

Lake of the Woods District Hospital

 BRIEFING – Before induction of anesthesia

All team members in the theatre and names written

• n white board beside corresponding roles (observers

included)  Patient information confirmed

Identity (2 identifiers) Consent: Site and procedure (by nurse)

Site, side and level marked

Clinical documentation: History, physical, labs, of significance

ANESTHESIOLOGIST: (WITH ALL TEAM)  Anesthesia equipment safety check completed Check sheet placed on patient chart  ASA score  Special precautions? _________________  Allergies? __________________________

 Medications  Beta blockers?  Glycemic control meds?

 PreOp Anticoagulant therapy (e.g., Warfarin)?  Preop Antibiotic administered

 Difficult Airway / Aspiration Risk

Confirm equipment available if required:



Specific patient concerns, critical resuscitation plan

 Monitoring – vs, O2 sat, Temp Probe,  Foley, Bair hugger (if applicable)  If blood loss issues  (G & M done & in chart) SURGEON : (WITH ALL TEAM)

Specific patient concerns, critical steps, and Special instruments or implants Final optimal positioning of patient

NURSES: (WITH ALL TEAM)

Sterility indicator Specific patient concerns? Equipment / implant readiness  PAUSE / TIME OUT – After draping /

immediately before incision Surgeon, Anesthesiologist, and Nurse verbally confirm

 Patient  Procedure  Site  Side  Level Is prep solution dry? Is all equipment connected and ready to proceed?

“Does anyone have any other questions or concerns before proceeding?”

 DEBRIEFING – As soon after skin closure as

possible / before patient leaves OR All team members review with entire team Surgeon states procedure performed

Important intra-operative events

Anesthesiologist reviews intraop events Recovery plans where there are KEY concerns for this patient’s recovery and management Changes to post-operative destination? Nurse reviews: Surgical count correct Specimen labeling accuracy  Any equipment malfunctions? Action taken?  _______________________________  _______________________________  _______________________________

Could anything have been done to make this case safer or more efficient?

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Pre-Anaesthesia Apparatus Checkout

• A. A. Pipelines

 Secure connections between terminal units (outlets) and anaesthetic machine

• B. B

C.

• D.  Check here

if this is a repeat case today with this machine: E.

• F. CHECKED

 items ____ to _____ 1 Turn on machine master switch and all necessary electrical equipment  line oxygen (40 – 60 psi or 275-415 KPa)  line nitrous oxide (40 – 60 psi or 275-415 KPa)  adequate reserve cylinder oxygen pressure  adequate reserve nitrous oxide content  check for leaks and turn off cylinders  flow meter function of oxygen and nitrous oxide over the working range.

• 2.  vaporizers filled /  filling port closed /  on-off functions work
• 3.  Functioning oxygen bypass (flush)
• 4.  Functioning oxygen fail-safe device
• 5.  Attempt to create a hypoxic 02/N20 mixture and verify correct changes in flow and/or alarm

6. functioning common fresh gas outlet 7. ventilator function verified 8. backup ventilation equipment available and function  cylinder,  Ambubag

• C. Breathing

Circuit

• 1.  circuit correctly assembled &  presser checked
• 2.  connected to common gas outlet
• 3.  Oxygen flow meter turned on
• 4.  Check for exit of fresh gas at face mask
• 5.  Functioning high pressure relief valve
• 6.  Unidirectional valves and soda lime
• 7.  Functioning adjustable pressure relief valve
• D. Vacuum

 Suction adequate

• E. Scavenging

 Correctly connected to patient circuit and functioning

• F. F. Routine

equipment

• 1. 1.  Airway Management

 Functioning laryngoscope (back up available)  Appropriate tracheal tubes: patency of lumen and integrity of cuff  Appropriate oropharyngeal airways  Stylet  Magill forceps

• 2. 2.  IV supplies
• 3. 3.  BP cuff of appropriate size 4.  Stethoscope
• 4. 5.  ECG monitor 6.  Pulse oximeter 7.  Capnograph 8.  Temperature monitor
• 5. 9.  Functioning low and high pressure alarms
• G. G. Drugs
• A.  Adequate supply of frequently used drugs and intravenous solutions
• H. H. special

equipment  Resuscitation apparatus is present and working  Defibrillators / crash cart  Emergency drugs  Difficult intubation kit  Glidescope  bronchosope Anaesthetic Machine Room Number:  O.R. # 1  O.R. # 2  O.R. # 3 DATE of inspection_________ TIME of inspection _____________ Anaesthetist Signature: _______________________________

Canadian Anesthesiologists’ Society, 2008.

Place patient identifier sticker here

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Cataract /IOL Surgery SURGICAL SAFETY

CHECKLIST

www.safesurgerysaveslives.ca

Your Organizational Logo Your Organizational Logo

Lake of the Woods District Hospital

Your Organizational Logo Your Organizational Logo

Lake of the Woods District Hospital

 BRIEFING – Before induction of anesthesia

Hand-off from day surgery nurse All team members’ names written on white board beside corresponding roles  Anesthesia equipment safety check completed Check sheet placed on patient chart Suction available  Patient information confirmed

Identity (2 identifiers) Consent: Site and procedure (by nurse) BIOMETRY (confirm patient ID on sheet) (by ophthalmologist) Clinical documentation: (by anesthetist)  History, physical, labs, of significance

 Special precautions?__________________  Allergies? _________________________

 Medications  EYEDROPS # of sets administered _____  Beta blockers?

 PreOp Anticoagulant therapy (e.g., Warfarin)?

 Difficult Airway / Aspiration Risk

Confirm equipment and assistance available

 Ophthalmologist review:

Specific patient concerns, critical steps, and special instruments or implants Final optimal positioning of patient

 Anesthesiologist(s) review(s)

Specific patient concerns, critical resuscitation plans, and warming devices required ASA Class

 Nurses(s) review(s)

Specific patient concerns? Sterility indicator passed? Equipment issues? Correct implant (and back up) available?

 Monitoring

Pulse oximetry, ECG, BP  PAUSE / TIME OUT – Before incision

Surgeon, Anesthesiologist, and Nurse verbally confirm

 Patient  Site, side  Procedure

“Does anyone have any other questions or concerns before proceeding?”

 DEBRIEFING – Before patient leaves OR

Nurse reviews with entire team

Important intra-operative events

 Specimen labeling and management (if required)  Equipment Malfunction? Action taken?  _______________________________  _______________________________  _______________________________ Changes to post-operative destination? What are the KEY concerns for this patient’s recovery and management? Could anything have been done to make this case safer or more efficient? Hand-off to RR

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ENDOSCOPY

SURGICAL SAFETY CHECKLIST

www.safesurgerysaveslives.ca

Lake of the Woods District Hospital

BRIEFING - ENDOSCOPY This discussion is held once all surgical staff has arrived in the operating room and prior to the administration of the neurolept Patient is usually awake and aware at this time. ■ Anaesthesia equipment safety check completed? ■ ASA class stated ■Monitoring – pulse

• ximetry on, ECG, BP,

■ Patient Information

• confirmed. - 2 identifiers,

consent states: procedure

• Documentation – H&P?

■ Allergies? ■ Prepared for biopsy to be done? ■ Disposable biopsy forceps/snares etc available? ■ Medications –Glycaemia control? ■ Off antiplatelets for appropriate length of time? (Plavix? ASA? NSAIDS?) ■ Anaesthesiologist:

• Any specific patient

concerns ■Surgeon

• any specific patient concerns

■ is cautery is required? ■ Nurse

• any specific patient concerns

■ Equipment checked / operating well ■ Suction / irrigator working? ■ Special precautions? TIME OUT Discussion occurs IMMEDIATELY before scope insertion ■ Surgeon, Anaesthesiologist and Nurses verbally confirm patient, procedure, ■ DOES ANYONE HAVE ANY OTHER QUESTIONS OR CONCERNS BEFORE PROCEEDING? DEBRIEFING This discussion occurs at “LIGHTS ON” phase Each professional reviews with the entire team Surgeon reviews:

• procedure,
• post op diagnosis
• CIRT RECORDING

■Anaesthesiologist: ■ KEY concerns for this patient’s recovery and post operative management

■ Nurse reviews:

■ specimen identification: ie: correct labelling and management ■ important intraoperative events including if equipment malfunctions

• ccurred

■ COULD ANYTHING HAVE BEEN DONE TO MAKE THIS CASE SAFER OR MORE EFFICIENT?

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Accomplishments

• First Small Hospital in Canada to adopt and fully

implement the Safe Surgery Saves Lives Program

• February 19 – April 30, 2009
• Significant “Good Catches” to date

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Challenges

• Those Who Said “This is for Big Hospitals – it does

not Apply to us”

• Nurses Needed to Become Comfortable Asking for

the Information

• Overcoming the Nay Sayers
• Adapt the Program to the Type of OR (small cases –

cataracts, colonoscopies)

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Successful Tactics

• Dependent on Organization Culture
• Dependent on Individuals Involved
• Type And Size of Organization
• Champions
• What Are Peers doing?
• Personal Persuasion Skills (soft management /

leadership skills)

• Mandatory Patient Safety Reporting Measure

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Benefits of Involvement

• This is About Improved Communication
• Very Economical to Implement
• Empowers Nurses to Speak out for Patient Safety
• Pride in Providing Safest Surgery Possible
• Research Proven to Save Lives and Prevent

Complications

• Participation in an International Program that

Identifies our Hospital as a Leader in Patient Safety

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LWDH Champions

• Sonia June Hill RN,MN, Manager Surgical Services
• Dr. Jack Spielman, Chief of Surgery
• Dr. Murray Workman, Chief of Anesthesia
• Brigitte Loeppky, OR Team Leader